1. Jeanine Spielberger MD 11/22/13 GBS SEPSIS PREVENTION INTERACTIVE CASES

2. CASE #1

3. Ms. J, A 24 year-old G1P0 female presents to OB triage with painful contractions for the past 2 hours. She is 35 weeks 1 day EGA dated by a certain LMP consistent with a 7 week ultrasound. She is otherwise asymptomatic, has no bleeding, and reports good fetal movement. She states “I thought they were just Braxton Hicks but now they are coming every 5 minutes so I wanted to get checked.” She reports no medical history, takes no medications other than prenatal vitamins, and states all prenatal labs have been normal. She has no medication allergies. FHT is reactive with baseline heart rate of 150, moderate variability, no decelerations. Tocometry shows contractions every 4-5 minutes. Her vital signs are temperature 98.7, HR 88, BP 117/86, RR 16, PO2 99% on room air. Her exam is notable for fundal height of 35, and sterile vaginal exam 0/0/-4. Photo courtesy of David Castillo Dominici/ freedigitalphotos.net

4. CASE #1 What is your next step? Mrs. J, A 24 year-old hispanic G1P0 female presents to OB triage with painful contractions for the past 2 hours. She is 35 weeks 1 day EGA dated by a certain LMP consistent with a 7 week ultrasound. She is otherwise asymptomatic, has no bleeding, and reports good fetal movement. She states “I thought they were just Braxton Hicks but now they are coming every 5 minutes so I wanted to get checked.” She reports no medical history, takes no medications other than prenatal vitamins, and states all prenatal labs have been normal. She has no medication allergies. FHT is reactive with baseline heart rate of 150, moderate variability, no decelerations. Tocometry shows contractions every 4-5 minutes. Her vital signs are temperature 98.7, HR 88, BP 117/86, RR 16, PO2 99% on room air. Her exam is notable for fundal height of 35, and sterile vaginal exam 0/0/-4. Photo courtesy of David Castillo Dominici/ freedigitalphotos.net

5. What is your next step?  Think about it then move to next slide… CASE #1

6. What is your next step?  This patient has pre-term contractions. Appropriate management steps include;  FHT monitoring,  checking for infectious causes of pre-term contractions  rechecking a sterile vaginal exam in 1-2 hours  Oral or IV fluids CASE #1

7. You recheck a SVE in one hour after giving 1 liter IV fluids, and note a change to 1/20/-3. She continues to have a reassuring FHT and stable vital signs. Her contractions continue every 4-5 minutes. She has no evidence of infection on wet mount/KOH or UA. CASE #1 What do you want to do now? What would you order? Photo courtesy of David Castillo Dominici/ freedigitalphotos.net

8. What do you want to do now? What would you order?  Think about it then move on to the next slide… CASE #1

9. What do you want to do now? What would you order?  This patient has a change in her cervical exam and therefore in preterm labor.  Appropriate management includes continued monitoring and periodic cervical exams.  Don’t forget to take a GBS culture and begin antibiotics! CASE #1

10. At what gestational age should you check a GBS culture? How long does a negative culture result stay good? Photo courtesy of cooldesign/ freedigitalphotos.net

11. At what gestational age should you check a GBS culture? How long does a negative culture result stay good?  Universal screening should occur at 35-37 weeks.  A negative culture result is valid for 5 weeks. If a woman has a positive urine culture or swab during the current pregnancy she should be considered GBS positive. CASE #1

12. Since this patient has not had a GBS culture you decide to check one at time of admission. Describe the correct method of obtaining a GBS culture. CASE #1 Photo courtesy of aopsan/ freedigitalphotos.net

13. Describe the correct method of obtaining a GBS culture. Vagina and rectum  Single swab or two swabs  Lower 1/3 of vagina  Through anal sphincter  Collection: NOT by speculum  Self collection an option CASE #1

14. Photo courtesy of arztsamui/ freedigitalphotos.net When would you start antibiotics?

15. CASE #1 Photo courtesy of arztsamui/ freedigitalphotos.net When would you start antibiotics? If patient is in preterm labor and GBS status is unknown antibiotics should be started at time of admission

16. Mrs. J’s contractions begin to space out and she feels less pain and pressure. Throughout the day vaginal exams remain stable at 1/20/-3. You monitor her for 24 hours and decide she is not truly in preterm labor. What is your management at this time? CASE #1

17. What is your management at this time? Her antibiotics should be stopped when it is established she is not in labor. CASE #1 Great job!. Photo courtesy of David Castillo Dominici/ freedigitalphotos.net You send her home with strict labor precautions and a follow up appointment with her PCP tomorrow.

18. CASE #2

19. Ms. K is A 24 year-old G1P0 female who presents to OB triage with painful contractions off and on for 2 days, worsening over the last 5 hours. She is 36 weeks 1 day EGA dated by a 10 week ultrasound. She is otherwise asymptomatic, has no bleeding or loss of fluid, and reports good fetal movement. She reports no medical history, takes no medications other than prenatal vitamins, and states all prenatal labs have been normal. GBS was collected in clinic and was positive, but susceptibility testing was not performed. Initially she had denied medication allergies but today her mother is at bedside and remembers her getting a rash after taking amoxicillin as a child. FHT is reactive with baseline heart rate of 150, moderate variability, no decelerations. Tocometry shows contractions every 4-5 minutes. Her vital signs are temperature 98.7, HR 88, BP 117/86, RR 16, PO2 99% on room air. Her exam is notable for fundal height of 36, and sterile vaginal exam 5/80/-2. CASE #2

20. Photo courtesy of stockimages/ freedigitalphotos.net What antibiotic will you start for GBS prophylaxis?

21. CASE #2

22. What antibiotic will you start for GBS prophylaxis?  This patient has a possible penicillin “allergy” but is not high risk for anaphylaxis.  Cefazolin is therefore the appropriate choice.  High risk history for anaphylaxis would include a reaction of anaphylaxis, urticaria, angioedema and/ or respiratory distress. CASE #2

23. Photo courtesy of stockimages/ freedigitalphotos.net What antibiotic would you choose if she had a high-risk allergy history to PCN?

24.  Since she did not have susceptibility testing she cannot be treated with clindamycin.  She should be treated with vancomycin.  Remember to include orders for susceptibility testing at time of GBS swab collection for patients with penicillin allergies. (This patient had denied allergy at time of collection so it was not tested.) CASE #2

25. You order cefazolin for intrapartum GBS prophylaxis and want to make sure she is adequately prophylaxed. What is the definition of “adequate” prophylaxis? CASE #2

26. What is the definition of “adequate” prophylaxis? 4 hours of penicillin, cefazolin, or ampicillin. CASE #2

27. She has an uneventful SVD 10 hours later of a male baby. His APGARS are 8/9. 30 minutes later you go to the nursery to assess him, and he is doing well with no resuscitation or extra support needed. CASE #2 The nurse asks “What orders you would like for the baby?” Photo courtesy of arztsamui/ freedigitalphotos.net

28. His nurse asks what orders you would like for the baby. This baby is preterm (defined as <37 weeks for the sake of the CDC criteria) and was adequately prophylaxed. No labs are needed UNLESS baby begins to show signs and symptoms of sepsis. CASE #2 Photo courtesy of arztsamui/ freedigitalphotos.net

29. Post-partum day one you round and find the parents dressed their bags packed and they anxiously ask you “when can we go?” What do you tell them? What if this had been a 38 week baby? CASE #2

30.  What do you tell them?  What if this had been a 38 week baby?  Because baby is preterm they need 48 hours of monitoring for signs/ symptoms of sepsis.  A term baby who received adequate prophylaxis and has no other risk factors may be discharged after 24 hours IF medical care is immediately available and IF family is capable of monitoring baby at home for signs/ symptoms of sepsis. CASE #2

31. Healthy mom and baby go home at 48 hours. Great job! CASE #2 Photo courtesy of David Castillo Dominici/ freedigitalphotos.net

32. CASE #3

33. Ms. L is a 30 year-old G3P1102 female presents to OB triage with complaint of fluid leaking and contractions. She is 37 weeks and 2 days EGA dated by 8 week ultrasound. She is otherwise asymptomatic, has no bleeding, and reports good fetal movement. She reports no medical history, takes no medications other than prenatal vitamins, and has no allergies. She received her prenatal care out of state and was here visiting family. She reports that all her labs were normal. When asked about GBS she says “Oh that test with the Q-tip? They did that last week but I didn’t get the results yet.” FHT is reactive with baseline heart rate of 140, moderate variability, no decelerations. Tocometry shows contractions every 4 minutes. Her vital signs are temperature 98.5, HR 78, BP 110/80, RR 18, PO2 99% on room air. Her exam is notable for fundal height of 38 cm, sterile speculum exam with gross pooling of clear fluid in the vaginal vault, and sterile vaginal exam 4/80/-2. CASE #3

34. What additional history would you ask?  Key historical elements would include duration of membrane rupture and previous birth history. If she had a previous baby with invasive GBS disease or was ruptured >/= 18 hours antibiotics would be indicated. What is your initial management?  Admit patient, try to get records. Antibiotics are not indicated based on the available history. CASE #3

35. Her two children were born healthy with no history of NICU stay. Her fluid leakage began last night, about 12 hours ago. You fax a record request to her PCP’s office and admit her to labor and delivery. CASE #3

36. Two hours later her SVE is unchanged. FHT is category 1, with baseline HR 145 She is uncomfortable with contractions every 3-4 minutes. Prenatal records are still not available. Would you change your management at this time? At what point would you consider antibiotics? What antibiotic would you use? CASE #3

37. Would you change your management at this time? At what point would you consider antibiotics? What antibiotic would you use?  When she has had ROM >/= 18 hours antibiotics are indicated. Penicillin would be the first choice, with ampicillin as an acceptable alternative. Some providers would choose to start antibiotics before 18 hours if the patient’s GBS status is unknown, and if in a case like this it looks fairly certain that she will not deliver in the next four hours. CASE #3

38.  At 18 hours you begin antibiotics for prolonged rupture of membranes. Two hours later her nurse calls as she is feeling an urge to push. You make it to the room just in time to deliver a male baby with APGARS 8/9. He appears vigorous and has no need for resuscitation. There is no foul odor to the amniotic fluid.  What would you include in your admission orders for baby? CASE #3

39.  This baby is term, had inadequate prophylaxis and prolonged rupture of membranes. He should have a limited evaluation including CBC and blood culture and should be observed for 48 hours.  Later that day you are called by nursing with concern that baby is tachypnic. On exam you note tachypnea with mild subcostal retractions and grunting. Exam is otherwise normal. Temperature is 98.5, HR 140, RR 88, PO2 96% on RA.  What is your next step? CASE #3

40. What is your next step?  You start ampicillin and gentamycin. Baby’s respiratory status improves and his blood cultures return negative at 48 hours. CASE #3 Photo courtesy of praisaeng/ freedigitalphotos.net